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Background : Recent data suggest that beta blockers are associated with increased perioperative risk in hypertensive patients. We investigated whether beta blockers were associated with an increased risk in elderly patients with raised preoperative arterial blood pressure. Methods We conducted a propensity-score-matched cohort study of primary care data from the UK Clinical Practice Research Datalink (2004–13), including 84 633 patients aged 65 yr or over. Conditional logistic regression models, including factors that were significantly associated with the outcome, were constructed for 30-day mortality after elective noncardiac surgery. The effects of beta blockers (primary outcome), renin–angiotensin system (RAS) inhibitors, calcium-channel blockers, thiazides, loop diuretics, and statins were investigated at systolic and diastolic arterial pressure thresholds. Results Beta blockers were associated with increased odds of postoperative 30-day mortality in patients with systolic hypertension (defined as systolic BP >140 mm Hg; adjusted odds ratio [aOR]: 1.92; 95% confidence interval [CI]: 1.05–3.51). After excluding patients for whom prior data suggest benefit from perioperative beta blockade (patients with prior myocardial infarction or heart failure), rather than adjusting for them, the point estimate shifted slightly (aOR: 2.06; 95% CI: 1.09–3.89). Compared with no use, statins (aOR: 0.35; 95% CI: 0.17–0.75) and thiazides (aOR: 0.28; 95% CI: 0.10–0.78) were associated with lower mortality in patients with systolic hypertension. Conclusions These data suggest that the safety of perioperative beta blockers may be influenced by preoperative blood pressure thresholds. A randomised controlled trial of beta-blocker withdrawal, in select populations, is required to identify a causal relationship.

This document is the result of a study of accounting and global perspectives in Bangladesh. Global scenarios are included in the survey to explain the scope of accounting practice. Accounting can be a blessing or a curse. This is the benefit of introducing something new to refine the accounting system, which adds to the body of existing accounting knowledge. When an unethical element invades, it becomes a curse. However, in the real world, accounting practices tend to show that in most cases they are curses rather than blessings and therefore undesirable. The main purpose of this practice is usually to attract unsuspecting investors, or to present unfair accounting by exaggerating, sometimes misleading, or misleading conditions in a company's financial position. Is to get the above reward. In recent years, accounting practices have increased not only in Bangladesh but also in many developed countries. However, It is clear that the scope of corporate financial statements presented in some developing countries violates all known ethical standards. This study emphasizes the need to prevent, rather than stop, corporate practices, if they exist. This document recommends the international introduction and recognition of forensic accounting. National accounting bodies, courts, and governments need to take strict measures to thwart this practice. Misrepresentation of facts or fraudulent financial reporting due to falsification of a company's financial statements should be considered a serious and punishable offense. Accountants must adhere to high ethical standards and maintain integrity in all professional activities. They need to ensure that accounting professionals are based on ethical principles and values, impose national and international respect and trust, and put an end to misleading accounting and financial reporting fraud.

Over the past 13 years bone marrow-derived mononuclear cells (BM-MNCs) have been widely investigated for clinical efficacy in patients following acute myocardial infarction (AMI). These early phase II trials have used various surrogate markers to judge efficacy and, although promising, the results have been inconsistent. The phase III BAMI trial has therefore been designed to demonstrate that intracoronary infusion of BM-MNCs is safe and will significantly reduce the time to first occurrence of all-cause death in patients with reduced left ventricular ejection fraction after successful reperfusion for ST-elevation AMI (powered with the aim of detecting a 25% reduction in all-cause mortality). This is a multinational, multicentre, randomized, open-label, controlled, parallel-group phase III study aiming to enrol approximately 3000 patients in 11 European countries with at least 17 sites. Eligible patients who have impaired left ventricular ejection (≤45%) following successful reperfusion for AMI will be randomized to treatment or control group in a 1:1 ratio. The treatment group will receive intracoronary infusion of BM-MNCs 2–8 days after successful reperfusion for AMI added on top of optimal standard of care. The control group will receive optimal standard of care. The primary endpoint is time from randomization to all-cause death. The BAMI trial is pivotal and the largest trial to date of BM-MNCs in patients with impaired left ventricular function following AMI. The aim of the trial is to provide a definitive answer as to whether BM-MNCs reduce all-cause mortality in this group of patients.

Background Preoperative blood pressure (BP) thresholds associated with increased postoperative mortality remain unclear. We investigated the relationship between preoperative BP and 30-day mortality after elective non-cardiac surgery. Methods We performed a cohort study of primary care data from the UK Clinical Practice Research Datalink (2004–13). Parsimonious and fully adjusted multivariable logistic regression models, including restricted cubic splines for numerical systolic and diastolic BP, for 30-day mortality were constructed. The full model included 29 perioperative risk factors, including age, sex, comorbidities, medications, and surgical risk scale. Sensitivity analyses were conducted for age (>65 vs Results A total of 251 567 adults were included, with 589 (0.23%) deaths within 30 days of surgery. After adjustment for all risk factors, preoperative low BP was consistently associated with statistically significant increases in the odds ratio (OR) of postoperative mortality. Statistically significant risk thresholds started at a preoperative systolic pressure of 119 mm Hg (adjusted OR 1.02 [95% confidence interval (CI) 1.01–1.02]) compared with the reference (120 mm Hg) and diastolic pressure of 63 mm Hg [OR 1.24 (95% CI 1.03–1.49)] compared with the reference (80 mm Hg). As BP decreased, the OR of mortality risk increased. Subgroup analysis demonstrated that the risk associated with low BP was confined to the elderly. Adjusted analyses identified that diastolic hypertension was associated with increased postoperative mortality in the whole cohort. Conclusions In this large observational study we identified a significant dose-dependent association between low preoperative BP values and increased postoperative mortality in the elderly. In the whole population, elevated diastolic, not systolic, BP was associated with increased mortality.

AIMS: The effect of combined cytokine and cell therapy in ischaemic cardiomyopathy is unknown. Meta-analyses suggest improved cardiac function with cell therapy. The optimal cell delivery route remains unclear. We investigated whether granulocyte colony-stimulating factor (G-CSF) alone or in combination with intracoronary (i.c.) or intramyocardial (i.m.) injection of autologous bone marrow-derived cells (BMCs) improves cardiac function. METHODS AND RESULTS: Ninety patients with symptomatic ischaemic cardiomyopathy and no further treatment options were enrolled in the randomized, placebo-controlled, single-centre REGENERATE-IHD study. Randomization was to one of three arms: peripheral, i.c., or i.m. In each arm, patients were randomized to active treatment or placebo. All patients, apart from the peripheral placebo group (saline only) received G-CSF for 5 days. The i.c. and i.m. arms received either BMCs or serum (placebo). The primary endpoint was change in LVEF at 1 year assessed by cardiac magnetic resonance imaging/computed tomography. The i.m. BMC group showed a significant improvement in LVEF of 4.99% (95% confidence interval 0.33–9.6%; P = 0.038) at 1 year. This group also showed a reduction in NYHA class at 1 year and NT-proBNP at 6 months. No other group showed a significant change in LVEF. This finding is supported by post-hoc between-group comparisons. CONCLUSION: We have shown that G-CSF combined with autologous i.m. BMCs has a beneficial effect on cardiac function and symptoms. However, this result should be considered preliminary in support of a clinical benefit of i.m. stem cell infusion in ‘no option’ patients and needs further exploration in a larger study.

Out-of-hospital cardiac arrest (OOHCA) is the leading mode of death in Europe and the United States. Emergency coronary angiography has a role in patients with OOHCA and ST-segment elevation, but outside of this group, its role is unclear. Intensive treatment of patients with an inevitably

Aims The REGENERATE-DCM trial is the first phase II randomized, placebo-controlled trial aiming to assess if granulocyte colony-stimulating factor (G-CSF) administration with or without adjunctive intracoronary (IC) delivery of autologous bone marrow-derived cells (BMCs) improves global left ventricular (LV) function in patients with dilated cardiomyopathy (DCM) and significant cardiac dysfunction. Methods and results Sixty patients with DCM and left ventricular ejection fraction (LVEF) at referral of ≤45%, New York Heart Association (NYHA) classification ≥2 and no secondary cause for the cardiomyopathy were randomized equally into four groups: peripheral placebo (saline), peripheral G-CSF, peripheral G-CSF and IC serum, and peripheral G-CSF and IC BMC. All patients, except the peripheral placebo group, received 5 days of G-CSF. In the IC groups, this was followed by bone marrow harvest and IC infusion of cells or serum on Day 6. The primary endpoint was LVEF change from baseline to 3 months, determined by advanced cardiac imaging. At 3 months, peripheral G-CSF combined with IC BMC therapy was associated with a 5.37% point increase in LVEF (38.30% ± 12.97 from 32.93% ± 16.46 P = 0.0138), which was maintained to 1 year. This was associated with a decrease in NYHA classification, reduced NT-pro BNP, and improved exercise capacity and quality of life. No significant change in LVEF was seen in the remaining treatment groups. Conclusion This is the first randomized, placebo-controlled trial with a novel combination of G-CSF and IC cell therapy that demonstrates an improvement in cardiac function, symptoms, and biochemical parameters in patients with DCM.

The second generation STENTYS Xposition S self-expanding stent with a novel balloon delivery system was launched in May 2015. The stents unique properties are well suited for the treatment of left main stem disease where large diameters, coverage of diameter differences and precise positioning are required. We report the first consecutive experience of using this device in the treatment of left main stem lesions.20 consecutive patients with a mean age of 73.9±10.1 years were treated over a period of 8 months at our institution and were assessed on the parameters of technical, angiographic and procedural success.Technical success was achieved in 95% of cases and angiographic success in 80% of cases. There was no incidence of geographical miss. Side branch access was straightforward, with no failure to recross stent struts, dilate or deploy a second stent if required. In this unselected clinical cohort, 2 critically ill patients with cardiogenic shock on presentation died despite successful revascularisation. There was no incidence of early stent related complications up to 30-day follow up.This first consecutive series of left main lesions treated with STENTYS Xposition S documents high acute technical and procedural success rates.

Background: Data are lacking on the optimal scheduling of coronary artery bypass grafting (CABG) surgery after stroke. The authors investigated the preoperative predictors of adverse outcomes in patients undergoing CABG, with a focus on the importance of the time interval between prior stroke and CABG. Methods: The Hospital Episode Statistics database (April 2006–March 2010) was analyzed for elective admissions for CABG. Independent preoperative patient factors influencing length of stay, postoperative stroke, and mortality, were identified by logistic regression and presented as adjusted odds ratios (OR). Results: In all, 62,104 patients underwent CABG (1.8% mortality). Prior stroke influenced mortality (OR 2.20 [95% CI 1.47–3.29]), postoperative stroke (OR 1.99 [1.39–2.85]), and prolonged length of stay (OR 1.31 [1.11–1.56]). The time interval between stroke and CABG did not influence mortality or prolonged length of stay. However, a longer time interval between stroke and CABG surgery was associated with a small increase in risk of postoperative stroke (OR per month elapsed 1.02 [1.00–1.04]; P = 0.047). An interaction was evident between prior stroke and myocardial infarction for death (OR 5.50 [2.84–10.8], indicating the importance of the combination of comorbidities. Prominent effects on mortality were also exerted by liver disease (OR 20.8 [15.18–28.51]) and renal failure (OR 4.59 [3.85–5.46]). Conclusions: The authors found no evidence that more recent preoperative stroke predisposed patients undergoing CABG surgery to suffer postoperative stroke, death, or prolonged length of stay. The combination of prior stroke and myocardial infarction substantially increased perioperative risk.

The field of autologous stem/progenitor cell therapy for cardiovascular diseases has moved rapidly from bench to bedside. In particular, a small number of pilot studies have demonstrated the safety and efficacy of this treatment in dilated cardiomyopathy (DCM), but this has to be validated in large randomized trials. Here we introduce the Bone Marrow Derived Adult Stem Cells for Dilated Cardiomyopathy (REGENERATE-DCM) trial, which to our knowledge, is the first randomized, double-blind, placebo-controlled trial worldwide to investigate the role of granulocyte-colony stimulating factor and autologous bone marrow-derived stem/progenitor cells to improve cardiac function in patients with DCM.

Cardiovascular disease is the leading cause of morbidity and mortality worldwide. Despite the advances in medical and catheter-based therapy for acute myocardial infarction the 1-year mortality remains as high as 13% and the 5-year prognosis for patients with heart failure remains as high as 50%. Left ventricular systolic dysfunction, a major determinant of prognosis, is associated with significant loss of cardiomyocytes which was previously thought to be irreversible as the heart was considered a post-mitotic organ.Review of literature published in peer reviewed journals and ClinicalTrials.Gov website.There is now growing evidence that the human heart is capable of undergoing repair and in recent years there has been an increase in basic and clinical research with the aim of harnessing the regenerative properties of stem cells in order to facilitate restoration of myocardial function.The mechanisms of action of cell therapy with regards to cardiac repair remain unsatisfactorily understood and the magnitude of benefit demonstrated in animal models is yet to be fully translated in humans.The number of clinical trials continues to increase and include treating patients with acute myocardial infarction and chronic heart failure secondary to ischaemic heart disease or dilated cardiomyopathy.The future of this field of research will require closer collaboration between scientists and clinicians to understand how cell therapy works and to define the ideal cell type and method of delivery to be able to derive maximum benefit.

Background The evidence for benefits of bivalirudin over heparin has recently been challenged. We aimed to analyse the safety and cost-effectiveness following reintroduction of heparin instead of bivalirudin as the standard anticoagulation for primary percutaneous coronary intervention (PPCI) in a high-volume centre. Methods and results This analysis was an open-label, prospective registry including all patients admitted to our centre for PPCI from April 2014 to April 2016. Heparin was reintroduced as standard anticoagulant in April 2015. During the 2 years, 1291 patients underwent a PPCI, 662 in the Bivalirudin protocol period (Cohort B) and 629 in the Heparin protocol period (Cohort H). Baseline and procedural characteristics were not significantly different, except for a higher use of thromboaspiration and femoral access in the earlier Cohort B. Glycoprotein 2b3a (Gp2b3a) antagonists were used in 24% of the patients in Cohort B versus 28% in Cohort H (P

OBJECTIVE: To assess the impact of proctoring for chronic total occlusion (CTO) percutaneous coronary intervention (PCI) in six UK centres. METHODS: We retrospectively analysed 587 CTO procedures from six UK centres and compared success rates of operators who had received proctorship with success rates of the same operators before proctorship (pre-proctored) and operators in the same institutions who had not been proctored (non-proctored). There were 232 patients in the pre-proctored/non-proctored group and 355 patients in the post-proctored group. Complexity was assessed by calculating the Japanese CTO (JCTO) score for each case. RESULTS: CTO PCI success was greater in the post-proctored compared with the pre-proctored/non-proctored group (77.5% vs 62.1%, p

Aim: This study presents an interim safety and feasibility analysis of the REGENERATE-IHD randomized controlled trial, which is examining the safety and efficacy of three different delivery routes of bone marrow-derived stem cells (BMSCs) in patients with ischemic heart failure. Methods & results: The first 58 patients recruited to the REGENERATE-IHD study are included in this interim analysis (pilot). Symptomatic patients with ischemic heart failure were randomized to receive subcutaneous granulocyte colony-stimulating factor or saline injections only; or subcutaneous granulocyte colony-stimulating factor injections followed by intracoronary or intramyocardial injections of BMSCs or serum (control). No significant differences were found in terms of safety and feasibility between the different delivery routes, with no significant difference in procedural complications or major adverse cardiac events. There was a signal towards improved heart failure symptoms in the patients treated with intramyocardial injection of mobilized BMSCs. Conclusion: Peripheral mobilization of BMSCs with or without subsequent direct myocardial delivery appears safe and feasible in patients with chronic ischemic heart failure.

A 33-year-old lady in the second trimester of pregnancy presented to the emergency department having suffered a cardiac arrest at home. An emergency caesarean section was performed in the resuscitation area. On return of spontaneous circulation, a 12-lead ECG showed anterior ST elevation myocardial infarction. She was transferred to our tertiary centre for an emergency coronary angiography and was successfully treated, making a full recovery. This case report examines the relatively rare entity of myocardial infarction in pregnancy and looks at the mechanisms underlying this.

In bifurcation stenting, three-dimensional Optical Coherence Tomography (3D-OCT) enables the assessment of jailing stent configurations at side branch (SB) ostia. Previous studies demonstrated that distal guide wire recrossing and favorable stent positioning were important to reduce the incidence of

Stem cell transplantation is emerging as a potential therapy to treat heart diseases. Promising results from early animal studies led to an explosion of small, non-controlled clinical trials that created even further excitement by showing that stem cell transplantation improved left ventricular systolic function and enhanced remodelling. However, the specific mechanisms by which these cells improve heart function remain largely unknown. A large variety of cell types have been considered to possess the regenerative ability needed to repair the damaged heart. One of the most studied cell types is the bone marrow-derived mononuclear cells and these form the focus of this review. This review article aims to provide an overview of their use in the setting of acute myocardial infarction, the challenges it faces and the future of stem cell therapy in heart disease.

Background Myocarditis is diagnosed in up to 10% of patients presenting as an acute coronary syndrome (ACS) who have elevated serum troponin and normal coronary angiogram. The diagnosis may be established by demonstrating typical patterns of abnormal tissue characterization at cardiac magnetic resonance imaging (CMR). Most reports examine left ventricular (LV) involvement; detecting tissue abnormalities in the right ventricle (RV) is limited by the technique’s spatial resolution. In patients diagnosed with myocarditis undergoing both acute and convalescent CMR scans, we studied changes in RV volumes to detect evidence of RV involvement.

A 50-year-old woman was referred to our cardiology department as part of an investigation for a possible cardiac embolic source of an ischaemic cerebral event. There was a strong maternal family history of hereditary haemorrhagic telangiectasia (HHT). The patient was a non-smoker and was not on the oral contraceptive pill. She presented to her optician with visual loss and was …

Aims Current national and international guidelines continue to recommend activation of the primary percutaneous coronary intervention (PPCI) pathway in patients presenting with chest pain and presumed new-onset left bundle branch block (LBBB). Previous research has suggested that a lower proportion of patients presenting with LBBB require emergency intervention. In this study we have compared baseline clinical characteristics, angiographic findings and subsequent outcome in patients with LBBB versus ST-elevation myocardial infarction (STEMI) referred to our tertiary centre for PPCI. Methods All patients accepted for PPCI within the period of September 2009 to November 2011 were included in the study. Patient data obtained from our Cardiac Services Database System (Phillips CVIS) were analysed and angiographic images reviewed on our Cardiac Image Database (McKesson Horizon). Mortality data were gathered from the Summary Care Record (SCR) database. Statistical comparisons of continuous variables were made by an unpaired t test. Categorical variables were compared using the χ 2 test. A p value of Results During the study period, 1875 patients were referred for PPCI of whom 155 (8.3%) had LBBB. Compared with STEMI, patients with LBBB were significantly older, more likely to be female and have prior history of MI and CABG (table 1). Patients with LBBB had similar door-to-balloon (DTB) and call-to-balloon (CTB) times. PCI was performed in 40 (26%) patients with LBBB although an acutely occluded culprit vessel was found in only 19 (12.2%) patients (table 2). Furthermore, 85 (54.8%) patients had non-flow limiting coronary artery disease and of those with significant disease 12 (7.7%) patients required CABG (figure 1). Overall, an acute coronary syndrome (defined as ischaemic chest pain with positive troponin) was confirmed in only 67 (43.2%) of patients presenting with LBBB. 30-day mortality was similar between LBBB and STEMI patients (table 2). However, during a mean follow-up period of 2.1 years, overall mortality was significantly higher in the LBBB group compared to STEMI (HR 2.01, 95% CI 1.26 to 3.20) (figure 2). Conclusions Our study shows that, in contrast to STEMI, only a small proportion of patients presenting with chest pain and LBBB had an acutely occluded coronary artery. Although short-term mortality was similar between the two groups, long-term outcome was significantly worse in patients with LBBB. Further work is needed to identify those patients presenting with LBBB who are most likely to have an acute coronary occlusion, in order to facilitate the appropriate use of emergency coronary angiography and PPCI.

Introduction Tako-tsubo cardiomyopathy (TCM) is increasingly being recognised in patients admitted with suspected acute coronary syndrome, as access to angiography and echocardiography are much quicker than before. Typically, patients with TCM present to the primary PCI service (PPCI) with chest pain and ST elevation on their electrocardiogram mimicking ST elevation myocardial infarction (STEMI). However, there is no ‘real-world’ data about the prevalence of this condition in PPCI admissions for suspected STEMI. Therefore we aimed to analyse the prevalence of TCM in a high volume regional PPCI service in UK. Methods All patients admitted with suspected STEMI between Sept 2009 and Nov 2011 to our centre were included. After excluding those who underwent PPCI, We analysed the echocardiogram and/or left ventriculogram of those patients who did not undergo PPCI to identify patients with typical TCM features of apical akinesia with basal hyperkinesia. Their coronary angiograms were reviewed and the inclusion criteria to identify TCM was the absence of significant coronary disease with no artery having >50% stenosis. Results Of the 1875 patients admitted, 17 (0.9%) patients (0 m, 17 f) with the mean age of 70±10.7 years (range 56–94 years) were identified to have typical TCM features. The prevalence of TCM in female PPCI admission was 3.1% (17/560) (figure 1). The admission ECG showed ST elevation in 14 patients (82%) and three had LBBB (18%). In those who had positive hsTroponin (n=16, 94.1%), the mean level was 921±668 (median 778, range 110–2550). Two patients had cardiac arrest prior to hospital admission with successful resuscitation. Left ventricular function was severely impaired (EF≤30%) in 2 patients whilst all others had moderately impaired LV function (EF 31–50%) (table 1). Aspirin, β-blocker, Angiotensin converter enzyme inhibitor (ACE-I) or angiotensin receptor blocker (ARB) was given to 13 (76.5%), 13 (76.5%) and 15 (88.2%) patients respectively on their discharge. All the 15 patients who had repeat echocardiogram within 3 months of their index admission showed complete recovery of their LV function. During a mean follow up period of 22±7 months (median 21, range 8–36 months), there was no mortality. Conclusions This first ‘real-world’ observational study of TCM in STEMI patients admitted for PPCI to a single centre showed an overall prevalence of 0.9% with 3% prevalence in female population. Although TCM is not benign during the acute episode, there is an excellent survival outcome if managed appropriately during the acute phase.